Evaluating Adherence to Guideline-Directed Medical Therapy in Patients With Advanced Heart Failure

Inclusion Criteria: 1. Age \> 18 and \< 75 years 2. Heart failure with left ventricular ejection fraction ≤ 35% 3. Persistent symptoms of heart failure, New York Heart Association class III or IV 4. Requirement for high-dose diuretic therapy, specifically Furosemide \> 50 mg/day orally as per routine clinical practice 5. At least one of the following additional indicators of severity or refractoriness: 6. need for progressive escalation of diuretics, 7. intolerance to optimized medical therapy, 8. persistence of symptoms despite advanced treatments such as (but not limited to) cardiac resynchronization therapy (CRT-D)and/or MitraClip 9. Ability and willingness to provide written informed consent for participation and for the processing of clinical data for research purposes Exclusion Criteria: 1. Age ≤ 18 years or ≥ 75 years 2. Left ventricular ejection fraction \> 35% 3. Mild or absent symptoms (New York Heart Association class I-II) 4. Good response to optimized conventional guideline-directed medical therapy 5. Extreme frailty or severe non-reversible disability, or psychiatric or cognitive disorders preventing adherence to follow-up 6. Pregnant or breastfeeding women